Acute Care: The Mentally IllDr. Jerry Morris, Medical Psychologist

Introduction• As if your acute care job isn’t complex &

demanding enough, let me do the psychologist’s destiny & bring the complex reality into focus! First, 24% of the population has an active mental disorder in any 24 month period (1 in 4 people you pass on the street, and treat in your hospital), as do 57% of the population (more than 1 of every 2) when lifetime prevalence is the time horizon (Morris, J. A., Practicing

Psychology in Rural Settings: Hospital Privileges & Collaborative Care, APA Books, Washington, DC, 1997).

Med/Surg Hospitals Have Always Treated the Mentally ILL• The point is this: “You are treating patients with

mental disorders, and the only question is whether you and the acute care hospital staff identify them, accurately diagnose them, adequately apply scientifically validated treatments and care plans for them, have skills and opportunities to grow in these skills specific to this large subpopulation of acute care patients, and whether you adequately prepare these patients for linkage with appropriate aftercare services and treatment.

Med/Surg Hospitals Have Always Treated the Mentally ILL• Tips & Pearls in Identifying Patients Needing

a Psychological Consultation: 1. Review of medications-ARE THERE PSYCH MEDS ON BOARD AT ADMISSION OR IN THE RECENT HX; 2. In your assessment, does the patient have a psychiatrist, psychologist, or mid-level mental health professional actively treating them on an outpatient basis; 3. Is there a family hx of MI or Substance Abuse; 4. Have there been frequent ED or Hospital admissions in the last year.

Caring for the Angry Patient• General Principles of Management• The safety of patient, clinician , staff ,other patients

and potential intended victims is of most importance while looking after aggressive patients

• The doors should be open outwards and not be lockable from inside or capable of being blocked from inside.

• while  working with impulsively aggressive or violent patients in any setting one must take care to reduce accessibility to patients  of movable objects as well as jewelry and other  attire that might add to the risk of injury during an assault, including neckties, necklaces, earrings, eyeglasses, lamps and pens.

Caring for the Angry PatientPrinciples of Management: Continued• Adequate caregiver training and the availability of

appropriate supervision are critical safeguards in the treatment of potentially dangerous patients.

• The caregiver may choose to present  a few key observations in a calm and firm but respectful manner, putting space between self  and patient; avoiding physical or verbal  threats, false promises and build rapport with client.

• For caregivers   treating patients with a high risk for violence behavior, training in basic self defense techniques and physical restraint techniques are useful.

Pharmaceutical Treatment• Drug Treatment in Aggressive and Violent

Behaviors

Medications are used primarily for 2 purposes-• To use sedating medication in an acute

situation to calm the client so that client will not harm self or others.

• To use medication to treat chronic aggressive behavior.

• Factors influencing choice of drug –availability of an IM injection, speed of onset and previous history of response.

Video Example & Training

Click Here to see video

Video Discussion• Call for help!• Ensure you have backup and the team

understands the situation (weapons, room dangers, lead up)!

• Logistics: entry and exit, safe distance, body language, respect!

• Non-threatening, honest identification of effect of the behavior on staff, engagement of pt. in problem solving and solutions.

Pharmaceutical Treatment• Drug Treatment in Aggressive and Violent Behaviors

• Acute agitation and aggression• Antipsychotic –often it is the sedating property of

antipsychotic that produce the calming effect for the client. Atypical antipsychotic are also commonly used. But only Ziprasidone is available in intramuscular form.

• Haloperidol-1 mg or 0.5 mg IM Risperidone o.5mg-1mg- In dementia and schizophrenia. Trazodone – 50-100mg . In older clients with sun downing syndrome and aggression.

• Benzodiazepines- used due to the sedative effect and rapid action. Most commonly lorazepam, oral or injection. Other sedating agents used include Valproate, chloral hydrate and diphenhydramine.

Psychopharmacology Tenets Options for Control

• Lorazepam (Ativan)• Midazolam (Versed)• Diazepam (Valium)• Haloperidol (Haldol)• Droperidol (Inapsine)• Diphenhydramine • (Benadryl)• Benztropine (Cogentin)• Ziprasidone* (Geodon)• Olanzapine* (Zyprexa,

Zydis)• Risperidone (Risperdal)• Aripiprazole* (Abilify)• Quetiapine (Seroquel)

ACEP Clinical Policy

Level B/C Recommendations

• Benzo OR a conventional antipsychotic

• If rapid sedation is required, consider droperidol* instead of haloperidol.

• Oral benzodiazepine + oral antipsychotic if cooperative patients.

• HAC may be faster than monotherapy

Lukens et al. Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Annals of Emergency Medicine. Vol 47, No 1, January 2006.

Benzodiazepines Expert Consensus Guideline 2005

• “BNZs are recommended when no data are available, when there is specific treatment (e.g., personality disorder), or when they may have specific benefits (e.g.,

intoxication).”

Allen et al. The Expert Consensus Guideline Series: Treatment of Behavioral Emergencies 2005. Journal of Psychiatric Practice. Vol 11, Suppl 1

• Why BZNs are Preferred for Undifferentiated Agitation

• Safe. No EPS. No Sz. No QT problems• Easy to titrate

Preferred for intoxications• Preferred for seizure, etoh

w/d.• Works some for psychosis• Preferred by patients

ETOH and AmphetaminesJust really drunk?

• Benzos vs antipsychotics?

• Project BETA recommends Haldol

• Some stick with Ativan and avoid midazolam

Wilson MP, Pepper D, Currier GW, Holloman GH, Feifel D. The Psychopharmacology of Agitation: Consensus statement of the American Association for Emergency Psychiatry Project BETA sychopharmacology

Workgroup. West JEM. In press

Psychotic from meth?• Ativan still good• Second Gen

Antipsychotics effective against meth psychosis.

Shoptaw SJ, Kao U, Ling W. Treatment for amphetamine psychosis. Cochrane

Database Syst Rev. 2009; 1: CD003026.

Expert Consensus“Within the limits of expert opinion and with the expectation that future

research data will take precedence, these guidelines suggest that : • SGAs are now preferred

for agitation in the setting of primary psychiatric illnesses

• But, BNZs are preferred in other situations.”

Allen et al. The Expert Consensus Guideline Series: Treatment of Behavioral

Emergencies 2005. Journal of Psychiatric Practice. Vol 11, Suppl 1

Project BETA Recommendations

• SGAs recommended over Haldol

• Risperidone or olanzapine if will take oral.

• Ziprasidone or olanzapine if IM

Wilson MP, Pepper D, Currier GW, Holloman GH, Feifel D. The

Psychopharmacology of Agitation: Consensus statement of the American

Association for Emergency Psychiatry Project BETA Psychopharmacology

Workgroup. West JEM. In press.

Second Line Approaches

What if that didn’t work?

• Change class?

• Add more benzo?

• Benzo after IM Zyprexa?

Chronic, Rather than Acute Aggressionbased on underlying diagnoses• Antipsychotic• Anxiolytics- Buspirone• Carbamazepine and valproate  to treat bipolar

associated aggressive behaviour.• Antidepressants –trazodone in aggression

associated with organic mental disorder.• Antihypersensitive medication – Propanolol to

treat aggression related to organic brain syndrome.

Responses to Lower Aggression

Use de-escalation techniques and

crisis communication to avert

aggressive behavior.

Tips and Pearls:

A. “I understand…..”

B. “I accept……….”

C. “But, …………”

Managing a psychiatric crisisIf your patient experiences a psychiatric crisis, use the following

techniques to help de-escalate the situation.

• Maintain a calm demeanor.

• Speak in a soft, clear voice.

• Convey empathy. For instance, ask, “How can I help you?”

• Allow the patient to vent.

• Listen to the patient; then reflect back what she has said so she

knows you’ve been listening. This may make her more likely to be

Receptive to you.• Use appropriate problem-solving techniques.• Offer reassurance and support. Let the patient know you’re trying

to ensure her safety.• Avoid a power struggle.• Don’t argue with the patient.• Keep your options open by avoiding definitive statements.